Tuesday, May 16, 2017

A New York state initiative to identify and transition some patients in assertive community treatment (ACT) programs to less intensive services so that others in need of such care can access it appears to be working: even as median time spent in ACT fell and turnover rates accelerated over a six-year period, the outcomes of those transitioned remained stable.

Those are among the findings of a report appearing in Psychiatric Services. Journal Editor Lisa Dixon, M.D. (pictured left), a co-author of the report, told Psychiatric News that the findings show the ways that statewide data can be used to influence care.

“ACT should be seen as one treatment in the care continuum, a step on the road to recovery,” she said. A vast literature since the 1980s has shown ACT to be effective in the care of individuals with serious mental illness. Originally, Dixon explained, it was believed that ACT needed to be sustained indefinitely; otherwise, patients would relapse. But, more recent evidence indicates that a subgroup of patients can successfully transition to less intensive care.

The New York State Office of Mental Health (NYSOMH) first implemented ACT statewide in the early 1990s. By 2008, 79 ACT teams were operating, with the capacity to serve about 5,000 people. By 2014, the ACT system had grown to 82 teams to meet the needs of approximately 5,200 people. During this period, as the waiting list grew, the state began to focus on transitioning participants through ACT so that additional patients could receive this service.

Strategies were developed to shift the ACT model from one in which patients would receive ACT care indefinitely to a model that routinely promotes participant transition to less intensive services. These included the development of an ACT Transition Readiness Scale (TRS) to monitor participants’ readiness for the transition from ACT, a learning collaborative focused on transition practices, and a biannual report for monitoring the flow of participants through ACT.

Between 2008 and 2014 the median time spent by individuals in the ACT program dropped by one year, from 44.4 months to 32.4 months. The percentage of participants who met ACT treatment objectives and transitioned from ACT rose from 13% in 2008 to 25% in 2014.

In addition, the percentage of Medicaid-eligible individuals with an ambulatory follow-up within 90 days of leaving ACT increased from 50% in 2008 to 61% in 2014, whereas the percentage with a psychiatric hospitalization within 90 days of disengagement from ACT decreased from 14% to 13%.

Dixon said that the effort is designed to allow ACT teams to use aggregated state-level data to inform decisions about individual patients. “Data are used as ‘touch points’ for looking at individual ACT participants,” she said. “This prompts a review of clinical opportunities to refocus the ACT team to recovery-oriented practices and to problem solve around barriers to transition to less intensive services.”

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